Acute complications of pregnancy
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Acute complications of pregnancy

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Dr Ibtisam

Dr Ibtisam

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Acute complications of pregnancy Acute complications of pregnancy Presentation Transcript

  • Acute complications of pregnancy
    Ibtisam Al Hoqani
    EM – R1
    22/6/2010
  • Outline:
    Complications in Early Pregnancy:
    Miscarriges
    Ectpic pregnancy
    Molar pregnancy
    :Complications in late pregnancy
    Abruption placenta
    Placenta Previa
    Preeclampsia and Eclampsia
    Medical & Surgical problems in pregnancy
  • Question 1:
    Which of following is the most common cause of first trimester vaginal bleeding?
    Abruptio placenta
    Ectopic pregnancy
    Placenta previa
    Spontaneous abortion
    Ovarian torsion
  • Miscarriage
    It is common, the overall embryponic and fetal loss rate after implantation ranges up to 1/3 of detectable pregnancy
    Spontaneous abortion:
    • Threatened
    • Inevitable
    • Incomplete
    • Complete
    • Missed
  • Question 2:
    A 26 years G1P0, 11 wks, presents to ED with vaginal bleeding. Bedside U/S confirm IU fetus with cardiac activity, VE: close cervical os, minimal bleeding, no adenxal tendernress. Bhcg sent. Mx incloude all except:
    Discharge with insterctions to come back if bleeding increased
    Bed rest fo 48 hrs
    Reassurance
    Inpatient admission for observation
  • Miscarriage
    Threatened abortion is most common cause of PV bleeding in primi
    It is PV bleeding, cervical os closed, IU normal pregnancy
    Mx:
    Bed rest for 48 hrs
    F/U with obs/gyne in 2-3 days
  • Miscarriage
    Inevitable abortion:
    Vaginal bleeding with open cervical os
    Mx: D&C
    Incomplete abortion:
    Vaginal bleeding with open cervical os and some POC passed or in the os or vaginal canal
    Mx: Remove visible POC to control bleeding, D&C
  • Miscarriage
    Complete abortion:
    All POC passed, os closed, uterus firm, non tender, and the bleeding almost stopped
    Mx: confirm by U/S , discharge or D&C if needed
    Missed abortion:
    Failure to pass POC after 2 months of fetal death
    Mx: medical or surgical D&C
  • Sonographic “discriminatory Zone”:
    The quantitive hCG at which a normally developing IUP should be seen;
    =6500 mIU/ml for TA U/S
    =3000 mIU/ml for TV U/S
    Criteria for abnormal pregnancy for TV U/S
  • Question:
    An 18 yrs present with sever LLQ pain and dizziness starting 4 hrs ago. T=36, PR=110, RR=30, BP=82/40, after 2L of saline hCG return positive and repeat vitals; PR=120, RR=30, BP=76/40, the best Tx:
    Administer IV antibiotics and arrange admission
    Check CBC, ESR, urinanalysis and continue fluid resuscitation
    Discharge home with antibiotics and analgesia
    Obtain TV U/S
    Immediate OB/GYN referral for laparoscopic surgery
  • Qusetion
    Which of following is not a risk factor for ectopic pregnancy:
    Previous C-section
    Pharmacological assisted conception
    Previous ectopic pregnancy
    Previous h/o PID
    Having IUCD
  • Ectopic pregnancy:
    Leading cause of maternal death in 1st trimester and 2nd overall cause of mortality in pregnant ladies
    Risk factors:
        Advanced age
    Pelvic inflammatory disease     Smoking
       Prior spontaneous abortionor ectopic pregnancy
       Medically induced abortion     History of infertility   Intrauterine device Tubal Surgery
  • Question:
    A 24 yrs female present to ED with 2 days vaginal bleeding and cramping. LMP 9 weeks ago, ED urine pregnancy test positive. Additional testing includes all except:
    Serum hCG
    Speculum and bimanual examination
    Culdocentesis
    CBC and blood group
    Pelvic ultrasound
  • Question:
    A 28 yrs present with acute onset of LLQ pain after unusually heavy bleeding, LMP: 4 wks ago. Pt pale, PR=130, BP=108/60, RR=24, T=36, After 1L of saline her vitals: PR=92, BP=118/70, RR=24, Urine PT post; what is most appropriate next step:
    Emergency U/S with immediate gyne referral
    Emergency U/S then call gyne accordingly
    Reassure and D/C with threatened abortion instructions
    Send CBC, cross match as appropriate and f/u with gyne within 24 hr
  • Ectopic pregnancy
    Management:
    Stable pt with un-ruptured EP <4cm by U/S ,,,, Methotrexate therapy
    Stable pt un-ruptured or minimally ruptured >4cm EP ,,,, Laparoscopic salpingectomy
    Unstable ,,, Laparotomy
  • Abruption placenta
    The cause of 30% of PV bleeding in 3rd trimester
    Premature separation of normally implanted placenta causing seen or hidden bleeding
    Usually associated with painfull uterine bleeding
  • Abruption placenta
    Stages:
    Grade 1: 40%, slight bleeding, no pain or fetal distress
    Grade 2: 45%, moderate bleeding, increase uterine irritability with fetal distress
    Grade 3: 15% tetanic uterine contraction, hypotension, coagulopathy, possible fetal death
  • Question:
    Which of following is not associated with increase incidence of Abruptio placenta?
    Cocaine
    Heroin
    Hypertension
    Smoking
    Advance age and Multiparty
    Abdominal trauma
  • Question:
    A 25 yrs G2P1, 24 wk of pregnancy, presents complaining of painless vaginal bleeding for 3 days, vitals: T=37.5, PR=92, BP=130/78, RR=20; what is best treatment plan for her?
    Ultrasound and outpatient OB F/U
    Urgent U/S with OBS/GYN refferal
    Send for CBC, blood group and weight result
    PV examination and send swap for c/s
  • Placenta Previa
    Cause 20% of 3rd trimester bleeding
    Painless bright red vaginal bleeding with soft non tender uterus
    Risk factors:
    • Prior C-section
    • Grand Multiparty
    • Previous placenta previa
    • Multiple gestation
    • Multiple induce abortion
    • Maternal age >40 years
  • Management
    Establish IV access, draw blood for cross match and basic work up, establish cardiac and fetal monitoring
    Immediately call for obstetric consultation if unstable otherwise do both ultrasound and OB referral
    Never do PV digital or speculum exam unless placenta previa rolled out
  • Question:
    A 36 yrs primi, 32wks, present with epigastric pain, her vitals normal except for BP=150/100, in ED she begins to seize, the next best action in Mx is?
    Hydralazine 10mg IV push
    Lorazepam 2mg IV push
    Phenytoin 20mg/kg IV
    MgSO4 6grm slow iv push
    Labetolol 20mg slow iv push
  • Preeclampsia and Eclampsia
    Pre-eclampsia:
    Elevated BP systolic >=140 or >=20 above baseline, and diastolic >=90 or 10 above baseline
    With proteinuria >0.3gm/24 hr
    Eclampsia
    Pre- eclamsia with grand-mal seizure or coma
  • Important facts:
    Eclampsia may occur without prior proteinuria
    Eclampsia can occur up to 10 days post partum
    Intracranial bleeding is the major cause of maternal death
    Warning sign of impending seizure:
    • Headache
    • Visual disturbance
    • Hyperreflexia
    • Abdominal pain
  • Question:
    Which of following is expected abnormality in HELLP syndrome?
    Decrease HGB
    Elevated PT
    Decreased Fibrinogen
    Elevated APTT
    All of above
  • Management:
    Pre- eclampsia:
    Anti-HTN not needed unless systolic BP >170 or diastolic >150, target BP sys 130-150 and dias 90-100
    Hydralazine is most commonly used but (Labetolol, nifedipine, nitroprusside) can be used
    ACE inhibitor are contraindicated
    Prophylactics MgSO4 is recommended
  • Question:
    A 38 yrs obese primi, 34wk, present with swelling leg and abdominal pain, BP=170/100, urine 3+protein, after giving MgSO4 and hydralazine, nurse toll u her urine output is low, what is best next step?
    Frusmide 40mg iv stat
    Maintained IV fluid
    Hydrochlorothiazide 25mg oral
    Mannitol 0.5mg/kg iv push
    25% albumin 1g/kg iv
  • Management:
    Eclampsia:
    Definitive Tx is delivery
    MgSO4: antiepileptic and anti-HTN
    Loading dose: 6mg IV over 15-20min then continuous infusion 2g/hr,
    Cardiac monitoring, and maintain urine output at rate >25ml/hr
    Follow DTR stop infusion if disappear
    Phenytoin or diazepam may be used for seizure resistant to MgSo4
  • Question:
    Which of following is sign of MgSO4 toxicity?
    Atrial Fibrillation
    Somnolence
    Increase
    Hyperventilation
    Diarrhea
  • Question:
    A 22 yrs, 36 wks pregnant after treating her with MgSO4 for preeclampsia, pt become somnolent with markedly decrease deep tendon reflex, and decrease RR, after managing her airway what is next best step?
    Dexamethasone
    Lidocaine
    Labetolol
    Calcium gluconate
    Atropine